Urology Coding Alert

Hernias complicate coding for treatment of hydroceles, spermatoceles or varicoceles. Urologists must consider the type of hernia as well as the age of the patient in coding these multiple procedures.
     
A hydrocele is an accumulation of excessive fluid around the testicle between the parietal and visceral layers of the tunica vaginalis. The hydrocele fluid is drained and the tunica vaginalis partially excised. Some tissue is left and sutured together behind the spermatic cord. Code removal of a hydrocele with 55040 (Excision of hydrocele; unilateral) if on one side and 55041 (... bilateral) if on both sides.
     
A spermatocele is a cyst in the area between the epididymis and the testis. The urologist excises the spermatocele with or without a partial excision of the head of the epididymis. Code removal of a spermatocele with 54840 (Excision of spermatocele, with or without epididymectomy).
     
A varicocele is a dilation of the veins in the spermatic cord into the scrotum. Code removal of a varicocele using 55530 (Excision of varicocele or ligation of spermatic veins for varicocele; [separate procedure]). (The separate procedure indication in CPT® means that the procedure, such as a varicocelectomy, is often integral to a more comprehensive procedure such as a hernia repair.)
  
Bilateral Billing

 
Codes 55530 and 54840 both carry a bilateral indicator of 1, which means you may report this code bilaterally using modifier 50 (Bilateral procedure).
 
There are separate codes for unilateral hydrocelectomy (55040) and bilateral hydrocelectomy (55041).

Hydrocelectomy and Hernia Repair

A hydrocele commonly occurs with a hernia. In pediatrics the two are so similar that the procedures are bundled. ""A hydrocele is the same as a hernia in pediatrics "" says Arthur Tarantino MD a urologist with Connecticut Surgical Group in Hartford, Conn. "The mechanism and the approach are similar for both." However, this is not true for an adult with a hernia and a hydrocele. 
 
Sometimes the general surgeon in the course of a hernia repair discovers a hydrocele and asks a urologist to repair the hydrocele. That coding scenario is simple: If the urologist performs only the hydrocelectomy and not the hernia repair bill 55040 with LT (Left side) or RT (Right side) appended to indicate left side/right side.
 
Sometimes the urologist assists the general surgeon in the hernia repair and hydrocelectomy. According to recent CPT® rules an assistant surgeon is a payable service with adult hernia repairs but not with hydrocelectomies. If the urologist assists in both and the patient is an adult, code only 49505 (Repair initial inguinal hernia, age 5 years or over; reducible) with modifier 80 (Assistant surgeon) appended. In children under age 5, code only 49500-80 (Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without hydrocelectomy; reducible; assistant surgeon). 

Adult Versus Pediatric Hydroceles

There's a clear distinction between adult and pediatric hydroceles, says Mark Cendron MD director of pediatric urology at Dartmouth Hitchcock Medical Center in Hanover, N.H. "Pediatric hydroceles are caused by a congenital condition called a patent process vaginalis or a communicating hydrocele," he says. "This hydrocele can turn into a hernia if a little piece of intestine comes down between the belly cavity and the scrotum." In adults there is a pocket of fluid caused by trauma or an inflammatory process such as epididymitis.
 
The surgical treatments differ as well. In an adult a hydrocele is treated via an incision in the scrotum. Usually hydroceles are only treated in adults when the pocket of fluid is large. In pediatrics the incision is in the groin. Repairing a pediatric hydrocele is almost always recommended, Cendron says, because of the communication between the body cavity and the scrotum. "It won't close down spontaneously," he says. "And over time the fluid may accumulate in the scrotum and may allow a hernia."
 
In adults, hydroceles are sometimes treated by draining the fluid pocket and then sometimes injecting an antibiotic, Cendron says. Code this procedure 55000 (Puncture aspiration of hydrocele, tunica vaginalis, with or without injection of medication).
 
Sometimes the urologist, particularly in the case of a pediatric patient, performs the hernia repair and the hydrocelectomy at the same time. Select the hernia code carefully: These codes are age-specific and refer to the type of hernia and some refer to hydroceles. CPT® advises to use excision codes in addition to hernia-repair codes.
 
The inguinal hernia codes are 49495-49525. Pediatric codes are 49495 (Repair, initial inguinal hernia, full term infant younger than age 6 months, or preterm infant older than 50 weeks postconception age and younger than age 6 months at the time of surgery, with or without hydrocelectomy; reducible), 49496 (... incarcerated or strangulated), 49500 (Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without hydrocelectomy; reducible), and 49501(... incarcerated or strangulated). Other hernia-repair codes are for "age 5 years or over" if initial (49505-49507) and "any age" if recurrent or sliding (49520-49525). The inguinal hernia-repair codes can be billed bilaterally.

Pediatric Hernias and Hydrocelectomies

All of the pediatric inguinal hernia repair codes include hydrocelectomies because the descriptors contain ""with or without"" verbiage.
 
For example, a pediatric urologist repairs an inguinal hernia on a 2-year-old boy and at the same time excises a hydrocele. Use 49500 or 49501 depending on whether the hernia is reducible incarcerated or strangulated. Do not bill separately for the hydrocelectomy; it's included in the hernia-repair code.
 
However, if the same pediatric urologist repairs an inguinal hernia on a 6-year-old the next day and this child also has a hydrocele excised two codes are required: 49505 for a reducible hernia or 49507 if the hernia is incarcerated or strangulated and 55040 if the hydrocele is unilateral. Append modifier 51 (Multiple procedures) to 55040.
 
Later the pediatric urologist repairs an inguinal hernia and excises a hydrocele on another 6-year-old except this time the hernia is bilateral and so is the hydrocele. Code 49505 with modifier 50 appended and 55041-51. No modifier 50 is needed on 55041 because that code descriptor states bilateral.
 
Note: A reducible hernia is one that can be pushed back into the cavity. With an incarcerated hernia there is no damage to the bowel vascular supply. With a strangulated hernia the blood supply to the bowel may be cut off. 
 
In about 5 percent of pediatric hernias the problem recurs, Cendron says. To code for repairing a recurrent hernia even in a child under the age of 5 use the 49520-49525 series. "Recurrent hernias are more difficult to repair because you have to go through scar tissue," he says. "You have to be careful not to injure other structures."

Varicocelectomy and Hernia Repair

The correlation between a hernia and a varicocele is much less clear than that between a hernia and a hydrocele. "In adults I'd be surprised to see them simultaneously," Tarantino says. "Usually a varicocelectomy is done for fertility not because there are any other symptoms." Hernias, however, cause pain.
 
Varicoceles are common in adults but usually require no repair. However when they require repair the reason is usually infertility. This repair is payable because you're still doing the repair for a varicocele. Code the varicocele as the primary diagnosis code and the infertility as the secondary diagnosis code.
 
If a varicocelectomy is performed with hernia repair, use 55530.
 
Spermatocelectomy Versus Epididymectomy

     
During a spermatocelectomy the surgeon removes cysts from the top of the epididymis. When the spermatocele is big or difficult to remove the urologist may need to remove part of the epididymis and do an epididymectomy. Often the choice isn't made until the surgery has begun.
 
Occasionally the epididymectomy must be done for chronic problems and sometimes it is done bilaterally.
     
When performed with a spermatocelectomy an epididymectomy is not separately payable. When performed alone, however, bill 54860 (Epididymectomy; unilateral) or 54861 (... bilateral).